What are the common causes of TMJ neck pain. How can you effectively treat TMJ-related neck discomfort. What preventive measures can help alleviate TMJ neck symptoms. Discover comprehensive insights into TMJ neck pain management.

Understanding TMJ Disorders and Their Impact on Neck Pain

Temporomandibular joint and muscle disorders (TMD) are conditions affecting the jaw joint and surrounding muscles. While primarily associated with jaw pain, TMD can also cause significant neck discomfort. In fact, up to 70% of individuals diagnosed with TMD report neck pain as a symptom. This connection between TMJ disorders and neck pain highlights the complex interplay between the jaw and cervical spine regions.

TMJ disorders can manifest in various ways, affecting not only the jaw but also the face and neck. The pain experienced in the neck is typically characterized by muscle tenderness and discomfort in the cervical spine area. This interconnected nature of TMJ-related symptoms underscores the importance of a comprehensive approach to diagnosis and treatment.

Common Symptoms of TMJ Disorders

• Pain in the jaw joint and surrounding muscles
• Facial pain and discomfort
• Neck pain and stiffness
• Clicking or popping sounds when opening or closing the mouth
• Limited jaw movement or lockjaw
• Teeth grinding (bruxism)
• Ear pain or ringing in the ears (tinnitus)
• Headaches
• Dizziness

The Intricate Connection Between TMJ and Neck Pain

The relationship between TMJ disorders and neck pain is rooted in the anatomical and functional connections between the jaw and cervical spine. The temporomandibular joint is closely linked to the upper cervical vertebrae through a network of muscles, ligaments, and nerves. When TMJ issues arise, they can create a cascade effect that impacts the surrounding structures, including the neck.

Several factors contribute to the development of neck pain in individuals with TMJ disorders:

1. Muscle tension: Prolonged jaw clenching or teeth grinding can lead to increased tension in the muscles of the jaw, face, and neck.
2. Postural changes: TMJ discomfort may cause individuals to alter their head and neck posture, leading to strain on the cervical muscles.
3. Referred pain: The close proximity of nerves in the jaw and neck region can result in pain referral from one area to another.
4. Compensatory movements: Individuals may unconsciously adjust their neck movements to accommodate jaw pain, leading to additional strain on the cervical muscles.

Diagnosing TMJ-Related Neck Pain: Challenges and Approaches

Diagnosing TMJ disorders, particularly when neck pain is a prominent symptom, can be challenging due to the lack of a standardized diagnostic test. Healthcare professionals often rely on a combination of clinical examinations, patient history, and imaging studies to make an accurate diagnosis.

Key Diagnostic Steps

• Comprehensive medical history assessment
• Physical examination of the jaw, face, and neck
• Evaluation of jaw movement and range of motion
• Palpation of muscles to identify tender areas
• Imaging studies (X-rays, MRI, CT scans) when necessary
• Assessment of bite alignment and dental health

It’s important to note that neck pain associated with TMJ disorders may mimic other conditions, such as cervical spine disorders or tension headaches. Therefore, a thorough differential diagnosis is crucial to ensure appropriate treatment.

Conservative Treatment Approaches for TMJ Neck Pain

When it comes to managing TMJ-related neck pain, healthcare professionals typically recommend starting with conservative, non-invasive treatments. These approaches aim to alleviate pain, reduce inflammation, and improve overall jaw and neck function.

Lifestyle Modifications and Self-Care Strategies

• Adopting a soft food diet to reduce stress on the jaw
• Applying heat or cold therapy to painful areas
• Avoiding extreme jaw movements and habits like nail biting
• Practicing stress-reduction techniques
• Maintaining proper posture throughout the day
• Using over-the-counter pain relievers or NSAIDs as directed

Physical Therapy and Exercise

Physical therapy plays a crucial role in managing TMJ-related neck pain. A qualified physical therapist can design a customized exercise program to:

• Improve jaw and neck flexibility
• Strengthen supporting muscles
• Correct postural imbalances
• Teach relaxation techniques
• Provide manual therapy to alleviate muscle tension

Oral Appliances and Splints

While the evidence supporting the effectiveness of intraoral appliances for TMJ disorders is limited, some individuals may find relief from using nightguards or stabilization splints. These devices are designed to reduce teeth grinding and alleviate pressure on the jaw joint. It’s crucial to consult with a dentist or TMJ specialist to ensure proper fit and avoid any permanent changes to bite alignment.

Advanced Treatment Options for Persistent TMJ Neck Pain

In cases where conservative treatments fail to provide adequate relief, healthcare providers may consider more advanced interventions. It’s important to note that these options should be approached with caution and only after careful consideration of potential risks and benefits.

Botulinum Toxin Injections (Botox)

Botox injections have gained attention as a potential treatment for TMJ disorders and associated neck pain. The procedure involves injecting botulinum toxin Type A into the muscles responsible for chewing. While some individuals report relief, the evidence supporting its efficacy remains limited. Further research is needed to establish the long-term safety and effectiveness of this approach.

Medications

In some cases, healthcare providers may prescribe medications to manage TMJ-related neck pain and associated symptoms. These may include:

• Muscle relaxants to reduce muscle tension
• Anti-anxiety medications to address stress-related symptoms
• Antidepressants, which can help with pain management and sleep issues

It’s crucial to use these medications under the guidance of a healthcare professional and to be aware of potential side effects and interactions.

Complementary and Alternative Therapies

Some individuals may find relief from TMJ neck pain through complementary therapies such as:

• Acupuncture
• Massage therapy
• Transcutaneous electrical nerve stimulation (TENS)
• Biofeedback

While these approaches may provide symptomatic relief for some patients, the scientific evidence supporting their efficacy in treating TMJ disorders is limited. It’s important to discuss these options with a healthcare provider and to use them in conjunction with, not as a replacement for, conventional treatments.

Surgical Interventions: A Last Resort for Severe TMJ Neck Pain

Surgery for TMJ disorders is generally considered a last resort due to its invasive nature and the potential for permanent changes to the jaw joint. Healthcare providers typically recommend surgical interventions only when all conservative treatment options have been exhausted and the patient continues to experience severe, debilitating symptoms.

Types of TMJ Surgery

• Arthrocentesis: A minimally invasive procedure to remove inflammatory byproducts from the joint
• Arthroscopy: A surgical technique using a small camera to diagnose and treat joint issues
• Open joint surgery: More extensive procedures to repair or replace damaged joint components

It’s crucial for patients considering surgery to thoroughly discuss the potential risks, benefits, and expected outcomes with their healthcare provider. Additionally, seeking a second opinion from a TMJ specialist is often recommended before proceeding with surgical interventions.

Preventing TMJ Neck Pain: Proactive Strategies for Long-Term Relief

While not all cases of TMJ disorders can be prevented, there are several strategies individuals can employ to reduce their risk of developing TMJ-related neck pain or exacerbating existing symptoms.

Lifestyle Modifications

• Practice stress management techniques such as meditation or deep breathing exercises
• Maintain good posture throughout the day, especially when working at a desk
• Avoid excessive gum chewing and nail biting
• Be mindful of jaw clenching or teeth grinding, especially during sleep
• Use proper ergonomics when working or engaging in physical activities

Dental Care and Oral Health

Maintaining good oral health is crucial in preventing TMJ disorders and associated neck pain. Regular dental check-ups can help identify and address potential issues early on. Additionally, addressing dental problems such as misaligned teeth or bite irregularities may help prevent the development of TMJ disorders.

Exercise and Physical Therapy

Incorporating targeted exercises and stretches into your daily routine can help strengthen the muscles supporting the jaw and neck, improving overall function and reducing the risk of pain. A physical therapist can provide guidance on specific exercises tailored to your needs.

Nightguards and Protective Devices

For individuals prone to teeth grinding or jaw clenching during sleep, wearing a custom-fitted nightguard can help protect the teeth and reduce pressure on the temporomandibular joint. These devices should be prescribed and fitted by a dental professional to ensure proper function and comfort.

When to Seek Professional Help for TMJ Neck Pain

While some cases of TMJ-related neck pain may resolve on their own or with conservative home treatments, it’s important to recognize when professional medical attention is necessary. Seeking timely care can prevent the progression of symptoms and improve overall outcomes.

Red Flags: Signs to Consult a Healthcare Provider

• Persistent or worsening pain in the jaw or neck
• Difficulty opening or closing the mouth
• Sudden changes in bite alignment
• Unexplained weight loss or asymmetrical swelling in the jaw or neck
• Hearing loss or persistent ringing in the ears
• Severe headaches or balance problems
• Pain that interferes with daily activities or sleep

If you experience any of these symptoms or have concerns about TMJ-related neck pain, it’s important to consult with a healthcare provider. They can perform a thorough evaluation, provide an accurate diagnosis, and recommend appropriate treatment options tailored to your specific needs.

Remember that early intervention and a multidisciplinary approach often lead to better outcomes in managing TMJ disorders and associated neck pain. By working closely with healthcare professionals and implementing preventive strategies, many individuals can find relief from TMJ-related discomfort and improve their overall quality of life.

TMJ neck pain: Causes, treatment, and prevention

Many people with temporomandibular joint and muscle disorders report pain in the jaw, but it can also cause a person to experience neck pain.

Temporomandibular joint and muscle disorders (TMD) is the term for several conditions that cause pain and dysfunction in the jaw joint and muscles that control jaw movement. People may also call them TMJ disorders.

TMJ is short for temporomandibular joint. This is the name for the two joints on either side of the jaw.

This article looks at whether pain associated with TMJ disorders can affect the neck. It also discusses how to treat the pain and how to prevent it.

TMJ disorders can cause a person to experience pain that affects the face, jaw, or neck. Up to 70% of people diagnosed with a TMD report neck pain as a symptom.

People will typically experience muscle tenderness and muscle pain in the cervical spine area. The cervical spine is the neck region of the spine.

Doctors usually recommend more conservative treatments.

According to the National Institute of Dental and Craniofacial Research (NIDCR), these include:

• eating soft foods
• applying heat or cold to the painful site
• avoiding extreme jaw movements
• avoiding nail biting, using chewing gum, or clenching the jaw
• learning and practicing jaw stretching and relaxing exercises
• using over-the-counter pain medicines or nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen
• participating in behavioral therapies such as cognitive behavioral therapy or biofeedback
• massaging the neck muscles

According to MouthHealthy, doctors may recommend medications, including anti-anxiety medications, muscle relaxants, or antidepressants.

A person can also try complementary treatments, such as acupuncture or transcutaneous electrical nerve stimulation (TENs). However, there appears to be limited evidence to suggest that these can help TMDs.

If these treatments are not effective, a doctor may recommend other forms of treatment.

Intraoral appliances

Intraoral appliances are devices that a person places directly inside the mouth. Other names include nightguards, splints, or stabilization appliances.

The NIDCR notes that evidence suggesting that there is limited evidence to suggest these are effective at treating TMD pain.

If a doctor recommends that someone use one of these, people should ensure that it is not designed to change their bite permanently.

People should also stop using them and consult a dentist or doctor if pain develops.

Botox

Botox involves injecting botulinum toxin Type A into the muscles needed for chewing. However, there is limited evidence to suggest the efficacy of Botox as a treatment for TMD.

Surgery

Experts suggest that people should avoid treatments involving surgery or that make permanent changes to the jaw or teeth, as there is not enough supporting evidence to suggest that these treatments work.

If conservative treatments have not worked, surgery may be an option for some people. This surgery permanently changes a person’s joints. This is why doctors do not recommend it often.

The way to prevent TMJ neck pain is by aiming to prevent TMJ disorders in general.

A person may wish to:

• wear a mouthguard at night to prevent teeth grinding
• regularly exercise and stretch to help strengthen muscles in the neck and jaw area
• maintain good posture
• have regular physical therapy
• avoid clenching the jaw
• try to stop nail biting
• avoid chewing gum

Other symptoms that a person may experience alongside neck pain include:

• pain in the jaw joint
• pain in the muscles responsible for chewing
• pain in other areas of the face
• hearing loss
• dizziness
• ringing in the ears
• ear pain
• misalignment of the teeth
• clicking, grating, or popping causing pain when opening or closing the mouth
• limited jaw movement or locking
• grinding of teeth

Some people may experience all the above symptoms, whereas others may only experience some.

There is currently no standard test to diagnose a TMJ disorder. Therefore, it can be difficult to receive a diagnosis. However, people should speak with a doctor if they have pain that does not resolve using home remedies and treatments.

Doctors may refer people to a physical therapist who can design a bespoke exercise plan for them to follow to improve the flexibility and strength of the jaw.

People should contact a doctor if they have experienced trauma to their jaw or surrounding areas that seem to have caused the pain.

Additionally, if any of the following symptoms occur, people should consider these ‘red flags’ according to a 2018 article:

• inability to open the mouth
• persistent pain
• worsening pain
• tinnitus
• difficulty balancing
• asymmetrical swelling of the jaw or neck
• hearing loss
• weight loss

Some people with TMDs find that their symptoms resolve without treatment.

If a person needs treatment, experts usually recommend that this treatment be conservative and reversible. This helps resolve TMDs in most people.

Neck pain is a common symptom of TMDs and can often cause people a lot of discomfort.

Lifestyle changes and conservative treatment is usually enough to remedy this pain.

In more severe cases, doctors may recommend surgery, but it is important to remember that this is not reversible and can sometimes be ineffective or even worsen the problem.

Do You Have TMJ? 8 Symptoms Not to Ignore

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Temporomandibular joint disease, or TMJ, is a complex condition that often worsens over time. Typically caused by the misalignment of the teeth, TMJ can erode the joint capsule between the skull and the jawbone. It is tricky to diagnose, and some people suffer for years. Once it is properly recognized, though, TMJ responds well to treatment. Here are 8 symptoms you should never ignore.

Not everyone experiences TMJ in the same way, but a clicking or popping sound in the jaw is an extremely common symptom. If this is your only symptom, you might not need treatment, but it is important to make your dentist aware right away.

2. Pain with Jaw Movement

When the teeth are not properly aligned, the jaw muscles try to compensate. Pain in the jaw or ear while chewing is common. Some people also experience pain when yawning or speaking.

3. Other Pain

TMJ can cause referred pain in the form of headaches, neck pain, shoulder aches, and even toothaches. The pain may worsen when moving the jaw, but it can sometimes be felt even at rest.

4. Locking Jaw

A lockup in the jaw can be a sign of TMJ. You might have difficulty opening your mouth wide or closing it again. When you do get it to move, your jaw will likely pop into place with a loud click.

5. Tired Facial Muscles

The muscles of your face may work hard to compensate for TMJ. If your face feels tired or saggy on one side, let your dentist know. Some people have persistent discomfort, while others experience it only after using the jaw.

6. Trouble Chewing

Since the jaw is out of alignment, many people with TMJ have trouble chewing. Your muscles will try to compensate, but this may be impossible if the misalignment is severe. You might feel like your teeth aren’t closing properly, and you might have extreme difficulty with foods that are crunchy or chewy. Check your bite in the mirror to ensure that your top and bottom teeth meet evenly without any straining or stretching.

7. Facial Swelling

It is relatively uncommon, but some people with TMJ have swelling on one side of the face, likely due to damage and inflammation in the joint capsule. The swelling may be mild or severe, and it might appear only after using the jaw or persist even at rest.

8. Nonspecific Symptoms

TMJ is challenging to diagnose because it can cause many different nonspecific symptoms. These may include, but are not limited to, dizziness, hearing difficulties, and ringing in the ears. Log any unusual symptoms you experience to discuss with your dentist at your next appointment.

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Dysfunction of the temporomandibular joint (TMJ): symptoms, causes and treatment

Dysfunction (dysfunction) of the temporomandibular joint (TMJ) is one of the most common joint pathologies ^[1] , often found in dental practice. According to some data, about 80% of dental patients have temporomandibular joint dysfunction syndrome ^[1]

The main symptoms of TMJ dysfunction

Diagnosis of TMJ dysfunction is difficult, since the disorder manifests itself in the form of multiple and varied symptoms ^[2] . There are frequent cases when they spontaneously (spontaneously) arise and disappear ^[1] .

One of the most striking symptoms of the disorder is pain. At the same time, they can be so intense and sharp that the patient loses the ability to normally chew and swallow food, speak, and open his mouth. Pain may be the only symptom of the disorder, or it may be accompanied by characteristic clicks in the joint and limited mobility of the lower jaw. It is not uncommon for dysfunction to manifest itself only with sound phenomena, while other symptoms are absent ^[2]

Pain in TMJ dysfunction is localized not only in the articulation itself, but in the area of ​​masticatory muscles ^[4] . In addition, pain and discomfort can manifest itself in the forehead and eyes, ears, temples, head in general, spread (radiate) to the neck, shoulders and back ^[4] .

Other most common symptoms include ^[4]

• tinnitus;

• feeling of pressure on the eyes and sensitivity to light;

• dizziness, nausea, lack of concentration;

• clicks and other sounds during jaw movement;

• swelling in the facial area (mainly in the area of ​​the joint).

The discomfort associated with TMJ dysfunction can be severe enough to significantly reduce a patient’s quality of life ^[4] .

Causes of TMJ dysfunction

There are many causes behind TMJ dysfunction. Among them ^{[1, 2]}

• disorders of the psycho-emotional state of patients;

• head (maxillofacial region) and neck injuries;

• dentition defects with impaired closure and chewing function;

• fillings and dentures in the oral cavity;

• pathological abrasion of hard dental tissues;

• dental anomalies;

• periodontal diseases;

• bad habits and others.

As a rule, these factors act in a complex manner and increase the negative influence of each other, leading to the development of TMJ diseases.

The mechanism of the development of disorders, according to experts, is quite complex. If the lower jaw is symmetrical, the muscles of the head do not experience any tension. But if for some reason there are problems with the bite, the function of the chewing muscles is disrupted. In response to this, the spatial position of the lower jaw also changes. To hold it, the muscles of the head, neck, torso and even the lower extremities are additionally strained ^[2]

For several months, and in some cases even years, the patient may not notice muscle tension. But if additional negative facts arise (stress, bruxism ), TMJ dysfunction develops ^[2] .

Arthritis and arthrosis of the temporomandibular joint

TMJ dysfunction leads to such dangerous pathologies as chronic arthritis, and then arthrosis of the joint ^[1] .

Arthritis of the TMJ is an inflammatory disease. Negative factors that can provoke its development are hypothermia, hormonal changes, and pathologies of the nervous system. Acute arthritis may be preceded by exacerbation of sinusitis, tonsillitis or otitis media ^[6] .

Symptoms of TMJ arthritis: joint pain that may radiate to different areas of the face. At the same time, pain is less intense at rest. In acute arthritis, there may be swelling in the joint area, the jaw is shifted to the affected side. The patient complains of general malaise, weakness, he may have an increased body temperature.

Arthrosis of the TMJ develops due to excessive stress on the joint. As a rule, this disease is accompanied by an irreversible change in the tissues of the joint, first cartilage, and then bone. Arthrosis often develops as a complication of arthritis of the temporomandibular joint. A characteristic symptom is a feeling of stiffness, pain in the jaw area after sleep and towards the end of the day ^[6] .

Arthritis and arthrosis of the temporomandibular joint can occur with complications and require complex, often surgical treatment. And in the absence of therapy, they can lead to serious conditions of the patient, limitation of his activity ^[7] and even disability ^[4] .

Treatment of TMJ dysfunction

TMJ dysfunction requires complex and long-term treatment, rehabilitation and subsequent prevention of recurrence of the disorder ^[4] .

Treatment of patients with TMJ dysfunction is a very complex and multifaceted problem. There cannot be a single and simple treatment regimen here, since the same correct diagnosis requires the doctor to influence various adverse factors that caused and continue to maintain the TMJ pain dysfunction syndrome in each patient -mandibular joint, Ph.D. Shemonaev V. I.

As a rule, the treatment of TMJ includes several directions ^{[4, 6]} .

1. Dental therapy. First of all, they carry out sanitation of the oral cavity (treatment of caries, pulpitis). In addition, if necessary, eliminate foci of infection in the oral cavity, tonsils, maxillary sinuses.

2. Orthopedic therapy. In order to normalize the bite, prosthetics are performed, grinding of irregularities in fillings.

3. Medical therapy. It is aimed at reducing chronic and acute pain with the help of a variety of pain medications and alleviating the patient’s condition. In addition, anti-inflammatory therapy is also carried out.

4. Physiotherapy. Includes electrical stimulation, ultrasound and magnetotherapy, phototherapy, compresses, massage. They help to relax muscles and eliminate spasms.

5. Therapeutic gymnastics. It should include exercises both for the chewing muscles and for developing a healthy posture and the habit of correct movements (the so-called motor stereotype).

6. Psychotherapy. Includes a variety of methods and tools aimed at reducing the overall stress of the patient (including conversations with a psychotherapist, auto-training, sleep restoration).

7. Other means. Used according to the specific symptoms of TMJ dysfunction and other diseases or conditions of the patient. For example, in case of manifestations of bruxism, special protective caps or splints are used to help eliminate involuntary grinding of the teeth and prevent abrasion of their surface.

Treatment of arthritis and arthrosis of the TMJ, in addition to general therapeutic measures, necessarily includes unloading the joints, for which they are trying to immobilize ^[6] . If the inflammation is purulent, the necessary surgical intervention (puncture) is performed. Also, surgical treatment is performed in complex cases of arthrosis, when the temporomandibular joint is subjected to significant deformation ^[6] .

List of sources

1. Vyazmin A. Ya., Podkorytov Yu. M., Klyushnikov OV Temporomandibular joint dysfunction and its treatment // Innovation Science. 2015. No. 1-2. URL: https://cyberleninka.ru/article/n/disfunktsiya-visochno-nizhnechelyustnogo-sustava-i-ego-lechenie (date of access: 20.02.2020).

2. Besschastny DS, Vyazmin A. Ya., Klyushnikov OV, Podkorytov Yu. M. Pathogenesis of temporomandibular joint dysfunction // Acta Biomedica Scientifica. 2010. No. 5. URL: https://cyberleninka.ru/article/n/patogenez-disfunktsii-visochno-nizhnechelyustnogo-sustava (date of access: 03/06/2020).

3. Shemonaev V. I., Mikhalchenko D. V., Kuznetsova O. A., Klimova T. N., Poroshin A. V. Dental rehabilitation of patients with combined pathology of occlusion and dysfunction of the temporomandibular joint // Volgograd Medical Scientific Research magazine. 2013. No. 2 (38). URL: https://cyberleninka.ru/article/n/stomatologicheskaya-reabilitatsiya-patsientov-s-sochetannoy-patologiey-okklyuzii-i-disfunktsiey-visochno-nizhnechelyustnogo-sustava (date of access: 03/06/2020).

4. Silant’eva EN Multidisciplinary approach to the diagnosis and treatment of craniomandibular dysfunction of the temporomandibular joint [Electronic resource] / EN Silant’eva // Topical issues of medical prevention, diagnosis and treatment of dental diseases: Sat. Art. intl. scientific-practical. Conf., Minsk, May 17, 2019 / Belorus. state honey. un-t, 2nd department. therapist. dentistry; under total ed. T. N. Manak, L. G. Borisenko, L. N. Polyanskoy. – Minsk, 2019. http://rep.bsmu.by/bitstream/handle/BSMU/23943/170_178.pdf?sequence=1&isAllowed=y (accessed 03/06/2020).

5. Yakupov BR, Gerasimova LP Diagnosis and treatment of muscular-articular dysfunction of the temporomandibular joint with pain syndrome // Medical Bulletin of Bashkortostan. 2013. No. 1. URL: https://cyberleninka.ru/article/n/diagnostika-i-lechenie-myshechno-sustavnoy-disfunktsii-visochno-nizhnechelyustnogo-sustava-s-bolevym-sindromom (date of access: 03/06/2020).

6. Artyushkevich AS Diseases of the temporomandibular joint // Modern Dentistry. 2014. No. 1 (58). URL: https://cyberleninka.ru/article/n/zabolevaniya-visochno-nizhnechelyustnogo-sustava-1 (date of access: 03/06/2020).

7. Tarasov IV, Nikitin AA et al. Conservative treatment of arthrosis of the temporomandibular joint // Bulletin of Modern Clinical Medicine. 2016. No. 4. URL: https://cyberleninka.ru/article/n/konservativnoe-lechenie-artroza-visochno-nizhnechelyustnogo-sustava (date of access: 20.02.2020).

Temporomandibular joint dysfunction as the most common cause of facial pain: current state of the problem

Orofacial pain is widespread in the population. Patients with facial pain seek medical advice from many specialties, including dentists, maxillofacial surgeons, neurologists, internists, and otorhinolaryngologists. Diagnosis of pain in the face can cause a serious difficulty for the doctor.

Pain in the face can be caused by a variety of reasons. In the International Classification of Head and Facial Pain, 3rd revision (ICHD-3 beta), pain syndromes in the facial area are given in Chapter 11 “Headache or facial pain associated with the pathology of the bones of the skull, neck, eyes, ears, nose, sinuses, teeth , oral cavity or other structures of the face and neck” and in chapter 13 “Painful cranial neuropathies and other facial pains” [1]. It should be noted that almost all sections in Chapter 11 use the term “headache (HA)”; only one section mentions facial pain as such (11.8). Chapter 13 refers to pain syndromes as “neuralgia” or “neuropathy.”

Most of the syndromes listed in the ICGB are not often encountered in the practice of a neurologist. One of the common mistakes in interpreting the cause of facial pain is the overdiagnosis of trigeminal neuralgia (TN) followed by prolonged and ineffective treatment with carbamazepine. At the same time, TN has been shown to be a relatively rare cause of facial pain [2].

This article focuses on temporomandibular joint dysfunction (TMJD). Today, TMD is regarded as the most common cause of chronic facial pain not associated with dental disease [3]. Facial pain associated with pathology in the region of the temporomandibular joint (TMJ) occurs in 19—26% of the adult population, and in women it is observed 1.5 times more often than in men [4, 5].

Clinical picture

Patients with TMD may experience pain in the face, maxilla and mandible, neck and shoulders, and in and around the ear. The pain may be constant or appear when chewing, talking, opening the mouth. Often the pain is also accompanied by a feeling of tiredness in the face and swelling.

In addition to facial pain, patients may experience headache, neck pain, earache, toothache, burning and stabbing sensations in the face, and shooting and puncture sensations. In addition to pain, there are also more rare and therefore even more difficult to diagnose symptoms: noise, ringing or congestion in the ears, non-systemic dizziness, and even itching or tingling in the head and neck. Pain may develop gradually, but many patients report an abrupt onset of pain and accompanying symptoms.

Difficulty chewing, inability to open the mouth wide, crackling/clicking when opening or closing the mouth, and blockage of the mandible are all indications of damage to the TMJ itself and facilitates diagnosis.

Diagnostics and differential diagnostics

Previously, TMD was considered exclusively as a pathology of the TMJ and as a consequence of subluxation of the lower jaw, arthritis, arthrosis or trauma of the TMJ, as well as occlusal disorders [6, 7]. However, in 2014, the TMD Diagnostic Criteria for Clinical Practice and Research (DC/TMD) was adopted by the International RDC/TMD Consortium Network and Orofacial Pain Special. interest group). In accordance with these criteria, TMD is divided into two groups: pain and intra-articular pathology; their combination is also possible [8].

A large number of patients with TMD have a painful form, i. e. pain in the area of ​​masticatory muscles, while the pathology of the joint itself is not detected. The literature describes pain in the face associated with myofascial dysfunction of the facial muscles [7, 9]. The authors indicate that during palpation of the muscles on the side of pain, a dense texture and muscle tension, especially masticatory and facial muscles, as well as severe pain and myofascial trigger points, were noted. On palpation of the masticatory muscle, the pain spreads to the upper and lower jaws, upper and lower molars, to the ear, to the frontal region, to the TMJ, to the neck. On palpation of the temporal muscle, pain radiates to the corresponding half of the head, forehead, upper teeth, and orbit. Since the prevalence of the painful form of TMDJ exceeds the prevalence of the intra-articular form [10], most patients can and should receive effective care from a neurologist. Thus, facial pain in a patient is most often caused by hypertonicity and myofascial pain syndrome in masticatory muscles without pathological changes in the structures of the joint itself.

When a patient presents with facial pain, the neurologist needs to conduct a proper examination (palpation) in order to diagnose and optimally treat such patients. This will avoid unnecessary referral of patients to dentists and ENT doctors and unnecessary and often painful examinations.

New criteria for the correct diagnosis of TMD are presented in the table.

Criteria for the diagnosis of TMD DC/TMD for use in clinical practice and research (adapted from [8])

Thus, according to the diagnostic criteria for TMD for clinical use, pain disorders are not associated with the pathology of the TMJ itself and can be represented by myalgia, arthralgia and HT associated with TMD. These criteria are based on the data of the anamnesis and clinical examination (palpation of the temporal and masticatory muscles) and do not require mandatory imaging studies. In myalgia, pain may be felt in the jaw, temple, ear, or anterior to the ear and usually changes with mandibular movement, chewing, or parafunctional activity. This means that pain in the face, ear, anterior and near the ear, as well as tinnitus may be symptoms of TMD and not indicate the presence of ENT pathology.

In the case of local myalgia, the pain felt by the patient is reproduced by palpation of the temporal and masticatory muscles within their palpable area. In myofascial pain syndrome, pain extends beyond the palpable area within or outside the palpated muscle (myofascial pain syndrome with referred pain).

It should be noted that for a complete diagnosis, it is necessary to follow the correct muscle palpation protocol: 3 points in the temporal muscle (anterior, middle and posterior sections) and 3 points in the masticatory muscle region (the beginning of the muscle, its body and its attachment site) [11]. Palpation is carried out with one or two fingers on each side separately or on both sides at once (depending on the convenience of the patient), the duration of pressing to determine myalgia should be at least 2 s, if it is necessary to determine the subtype of myalgia, at least 5 s. In practice, it is also possible to palpate the masticatory muscle by pressing it with the researcher’s thumb in the patient’s mouth and with the rest of the fingers outside.

To determine the presence of arthralgia, it is necessary to confirm that the pain felt by the patient in the face is localized in the TMJ region and is reproduced during provocative tests: palpation in or around the condylar process of the mandible or with maximally active or passive mouth opening, lateral movement or protrusion of the mandible .

In the case of localization of pain in the parotid region anterior to the auricle, it can be difficult for the clinician to determine the specific structure involved. In this case, it is necessary to determine whether the pain is localized in the region of the condylar process of the lower jaw (arthralgia) or the masticatory muscle. In the latter case, one of the types of myalgia will be diagnosed. To determine the location of the condylar process of the jaw and confirm the source of pain felt by the patient, it is necessary to palpate the anterior region with the mouth closed. In case of difficulty, palpation should be performed when opening the mouth or protruding the lower jaw forward (Fig. 1).

Rice. 1. Palpation to locate the condylar process of the mandible. a – with a comfortable closing of the mouth; b – with protrusion of the lower jaw.

To find the points of palpation of the masticatory muscle, ask the patient to clench and then unclench his teeth. In this case, the definition of the boundaries of the palpated muscle is greatly simplified (Fig. 2).

Rice. 2. Palpation of the masseter muscle to determine the form of TMD. a – the place of the beginning of the muscle; b – muscle body; c — zone of muscle attachment.

Palpation of the temporal muscle is much easier. It is necessary to palpate at least 3 points in the anterior, middle and posterior portions of the muscle (Fig. 3). In case of difficulty in finding the boundaries of the temporal muscle, it is necessary to ask the patient to clench his teeth.

Rice. 3. Palpation of the temporal muscle in order to determine the form of TMD. a – anterior portion of the muscle; b – the average portion of the muscle; in — a back portion of a muscle.

Another type of pain form of TMD is TMJ associated with TMD. In ICHD-3, beta HT associated with TMD is referred to as secondary cephalalgia and is described as “HT caused by a disorder involving structures in the TMJ area” [1]. The first two items are non-specific criteria confirming the secondary nature of the pain; only item 3 contains TMD-specific characteristics: GB is provoked or exacerbated by active jaw movements, passive movements in the usual range of jaw mobility, and/or provocative tests with temporomandibular structures, such as pressure on the TMJ and surrounding masticatory muscles. However, the commentary on the diagnostic criteria contains a recommendation from the International Headache Society to use newer and more accurate criteria developed by the RDC/TMD International Network Consortium and the Orofacial Pain Research Group to fully diagnose and clarify the causes of pain associated with TMD.

Differential diagnosis of HT associated with TMD includes other forms of primary and secondary cephalgia. When conducting a differential diagnosis, it is necessary to rely on the known diagnostic criteria for these cephalalgias. In the case of strictly unilateral HA, it is necessary to exclude migraine and cervicogenic GB. Patients with migraine are characterized by provocateurs of a painful attack that are not typical for TMD, migraine symptoms accompanying an attack (nausea, vomiting, phono- and photophobia), often a hereditary history of G.B. To confirm the diagnosis of cervicogenic HA, rotational tests and diagnostic blocks of cervical structures are used [1]. In the case of bilateral localization of pain, difficulties may arise in the differential diagnosis with tension headache, combined with tension of the pericranial muscles. In this case, the inspection and palpation shown in Fig. 1-3 are of key importance for diagnosis.

Intra-articular forms of TMD are somewhat less common in the practice of a neurologist. It should be noted that in many cases the identified intra-articular pathology is combined with the pain form of TMD and is not isolated.

In the presence of damage to the TMJ itself, there are several forms of TMD. With various forms of displacement of the intraarticular disc with reduction, different intracapsular sounds are noted during palpation of the joint and movements of the lower jaw: crunching, crackling, clicking. Disc displacement without reduction is usually caused by spasm of the lateral pterygoid muscle [12]. When the disc is displaced without reduction, there is a pronounced restriction of mouth opening and a violation of the ability to eat. In the case of degenerative pathology of the disc, a coarser (similar to grinding) and long sound can be noted – crepitus caused by friction of the damaged intraarticular disc. Blockage of the TMJ when the mouth is open and the inability to close the mouth without an assisted maneuver are indicative of mandibular subluxation.

Examination rules for the diagnosis of intra-articular form of TMD are shown in fig. 4. To confirm the diagnosis of various intra-articular forms of TMD, it is necessary to conduct an MRI examination of the joint.

Rice. 4. Palpation aimed at detecting sounds in the TMJ. a — when opening/closing the mouth; b – lateral movement of the jaw to the right; c – lateral movement of the jaw to the left; g – protrusion of the lower jaw. Palpation is carried out sequentially on each side.

Etiology and pathogenesis of TMD

The etiology of TMD is multifaceted and is a combination of psychological, postural, orthopedic, genetic, biopsychosocial and occlusive factors that disrupt the functional balance in the structures of the TMJ itself and the surrounding muscles [6, 13, 14].

The view on the pathophysiology of TMD cannot be considered finalized. In 1934, James Costen gave the first systematic description of this group of diseases, indicating occlusion failure as the main cause. For many years, it was believed that the cause of myogenic and articular disorders in TMDJ is malocclusion (occlusal disorders, missing teeth, suboptimal prosthetics, chewing on one side and other causes) and parafunctional activity (night and/or daytime bruxism), which leads to increased load on the TMJ and muscles that provide chewing (temporal, chewing, medial and lateral pterygoid). A significant role was also assigned to injuries of the face and lower jaw and emotional disorders. In particular, the presence of symptoms of depression doubles the likelihood of developing the arthralgic form of TMD, and anxiety disorders often accompany myalgia in TMD [15, 16]. Some authors [7] point to the role of orthopedic disorders (for example, short leg syndrome) in the genesis of TMD. An orthopedic examination in a significant number of patients (66%) reveals asymmetries of the shoulders, shoulder blades, shortening of one leg, which causes a compensatory change in posture and muscle imbalance throughout the entire spine. The “forward head posture” also has a serious influence on the occurrence of the myogenic form of TMD [17].

However, in recent years, a number of authors have expressed doubts about the exclusive role of dental pathology in the development of TMD. Point to the frequent combination of TMD and various types of GB. In patients with TMD, the most common primary form of HA is migraine (55.3%), the prevalence of HA is 30.2% [18]. According to other authors [19], the prevalence of TMD in patients with chronic daily HA is 58.1%.

In recent years, in the works of leading Russian and foreign researchers of chronic pain [20—22], for the first time, suggestions were made about possible central causes of TMD, in particular, about the role of a possible dysfunction of pain control systems. Thus, it has been shown that the prevalence of the pain form of TMD in chronic migraine significantly exceeds that in episodic migraine. The authors hypothesized that pain and myofascial pain syndrome in TMD may be caused by impaired processing of pain impulses in the CNS and are not associated with peripheral/dental factors.

Treatment

Based on the current understanding of the pathophysiology of TMD, a range of treatments have been developed. In neurological practice, the treatment of TMD includes a wide range of non-drug and pharmacological approaches:

1. Patient education. Educating patients about the causes and form of TMD and the importance of behavior modification (eg, actively focusing on not clenching teeth) is important. In case of acute pain, it is necessary to recommend a temporary refusal to eat solid food and open the mouth wide.

2. Non-steroidal anti-inflammatory drugs (NSAIDs) are often the first choice and are effective in managing TMD pain. Among a large group of NSAIDs, the drug nimesulide (nise) deserves special attention. The difference in clinical efficacy and tolerability of different NSAIDs may be due to different selectivity for inhibition of COX-1 and COX-2. Nimesulide is predominantly a COX-2 inhibitor with a wide range of additional actions, which helps to explain its specific anti-inflammatory and analgesic activity. More than 200 clinical studies have evaluated the effectiveness of nimesulide in a wide range of pain syndromes (tooth extraction and other dental operations, GB, back pain, joint pain, dysmenorrhea). In these studies, nimesulide systematically demonstrated a reduction in inflammatory pain significantly superior to placebo and at least equal to or in some cases even more effective than other NSAIDs [23].

The main clinical benefit of nimesulide is the time to onset and duration of pain relief. Compared with other NSAIDs, nimesulide has a faster onset of analgesic action, namely 15 minutes after ingestion [24], it should also be noted that a rapid onset of action was noted in patients with chronic pain syndrome.

A significant advantage of this drug is a lower relative risk of complications of the upper gastrointestinal tract compared with non-selective NSAIDs due to the predominant effect on COX-2. However, a single dose of nimesulide provided higher efficacy and a faster onset of analgesia than comparable single doses of selective COX-2 inhibitors such as celecoxib and rofecoxib [25]. When comparing nimesulide with the non-selective NSAID diclofenac, the drug showed comparable efficacy, but better overall tolerability [26].

The overall risk of severe liver reactions associated with the use of NSAIDs is low. The incidence of liver damage associated with the use of nimesulide is within the frequency range for other NSAIDs [23].

The use of all NSAIDs is associated with some cardiovascular risk and in patients with arterial hypertension, hypercholesterolemia and cardiovascular disease, all NSAIDs should be used with caution, especially in the elderly. Risks and benefits should be assessed on an individual basis and the lowest effective dose is recommended for the shortest possible period of time. Many data indicate that nimesulide demonstrates a low overall risk of cardiovascular events such as myocardial infarction or congestive heart failure [27].

An international panel of experts concluded that, when used appropriately, nimesulide remains an extremely important and safe treatment option for various conditions characterized by the presence of acute inflammatory pain, due to the rapid onset of analgesic action and a proven positive benefit/risk profile [23].

Nise is recommended for TMD at a dose of 100 mg twice daily. The duration of its use, like other NSAIDs, should be limited to the minimum necessary time.

3. Gymnastics . After applying a cold compress, exercises are performed to stretch the masticatory muscles, then a warm towel must be applied.

4. Cognitive behavioral therapy and biofeedback are also highly effective.

For chronic TMD it is recommended:

1. Administration of the tricyclic antidepressant amitriptyline (up to 75 mg/day). The choice of amitriptyline as a first-line drug is due to the relatively high risk of developing bruxism while taking selective serotonin reuptake inhibitors [28].

2. Referral of the patient to the dentist for the selection of a special muscle relaxant splint (especially in the case of nocturnal bruxism) and assessment of the presence and correction of occlusal disorders.

3. In case of myofascial pain syndrome, it is possible to inject anesthetic into trigger points in masticatory, temporal and pterygoid muscles.

4. Treatment with botulinum toxin type A for the painful form of TMDJ, which has demonstrated high efficacy in a large number of studies [9, 29]. Such therapy can not only achieve long-term and sustainable relaxation of the muscles of the masticatory group and relieve pain associated with myofascial pain syndrome in these muscles, but also a temporary remission of nocturnal bruxism, which will reduce the risk of developing an intra-articular form of TMD.

5. Carrying out complex treatment of comorbid diseases, in particular depression, anxiety disorders, chronic pain.

6. In case of proven presence of intra-articular form of TMD, dysfunction of the jaw and lack of effect of conservative therapy, the patient should be referred to an oral surgeon [30].

TMD is considered today as the most common cause of chronic facial pain not associated with dental disease. It has been shown that facial pain in many cases is caused by hypertonicity and myofascial syndrome in masticatory muscles without pathological changes in the structures of the joint itself. Since the prevalence of the painful form of TMDJ exceeds the prevalence of the intra-articular form, most patients can and should receive effective care from a neurologist. For a complete diagnosis of the nature of TMD, one should rely on the DC/TMD diagnostic criteria for clinical use. These criteria are based on the history and clinical examination (correct palpation of the temporalis and masticatory muscles) and do not require mandatory imaging studies. If typical symptoms of intra-articular pathology (primarily sound) are detected, an MRI of the joint is indicated to confirm the diagnosis.

TMD is currently considered a disease with a multifactorial etiology. Myofascial pain syndrome in the muscles of the masticatory group can be considered as a manifestation of a violation of antinociceptive functions, i.e., it is a reflection of central sensitization and a violation of downward pain control.

Treatment of the painful form of TMD at the first stage should be carried out by a neurologist.